SONOWORLD : Ultrasound case Renal Cell Carcinoma
 
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Abdomen » Kidneys/Ureters
Renal cell carcinoma with renal vein and IVC tumour thrombus
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Presentation
M78YO.  Reason for exam on U/S request: AoCRF, eGFR 14, Hx IVC Thrombus/CCF.  CT Abdo – Abnormal Right Kidney ?RCC.  Also has free fluid RIF with some inflamm stranding.

Reason for CT exam 5 days prior to ultrasound request: 2/52 Hx of worsening Upper Abdo pain and RUQ pain raised bilirubin –
? Cholelithiasis need to rule out AAA.  Can’t use contrast – worsening renal fx. Review of prev CT showed findings as above.
Findings: Right renal solid mass +/- 5cm.  Para-aortic lymph nodes, fluid & stranding in RIF. ^^ ** IVC markedly dilated up to 4.2 cm
(in keeping w hx of IVC thrombus, seen on recent Echo)

Conclusion: Solid mass of mid segment of RK concerning for RCC with Right Renal vein/IVC tumour thrombus, further characterization with Ultrasound suggested.
 
 
 
Caption: Long axis Right kidney
Description: Probable RCC tumour of supero-mid pole. Note the disruption of the normal renal outline caused by the almost iso-echogenic mass
 
 
 
Caption: Transverse view of the Right Kidney
Description: This image shows the renal tumour extending beyond the edge of the image. The dilated RRV is filled with tumour thrombus that extends into the IVC.
 
 
 
Caption: Transverse mid upper abdomen
Description: In this transverse view through the liver, aorta and IVC, the dilated IVC filled with tumour thrombus is well seen. Only a small crescent residual lumen remains.
 
 
 
Caption: Transverse Liver, upper abdomen
Description: In this transverse view at the level of the hepatic vein confluence a tongue of tumour thrombus is seen within the lumen of the IVC.
 
 
 
Caption: Sagittal upper abdomen through IVC
Description: Tumour thrombus expanding the IVC with a tongue of thrombus extending to the level of the hepatic vein confluence. No right atrial involvement seen.
 
 
 
Caption: Transverse Left Kidney
Description: The left kidney and renal vein appear normal.
 
Differential Diagnosis Solid renal mass, tumour thrombus
 
Final Diagnosis

Solid renal mass, probably renal cell carcinoma with tumour thrombus of right renal vein & IVC – extending to the level of the hepatic veins confluence. 

 
Discussion Patient presented with extensive chronic history including Diabetic, GORD, CCF, Chronic Kidney Disease.  Increasing Fluid Overload & decreasing renal function lead to CT & renal/abdomen Ultrasound.  Prior CT has indicated a probable RCC with tumour thrombus extending into the IVC.  Ultrasound confirmed solid renal mass and tumour thrombus extending into the IVC.

The extent of tumour thrombus may be classified as follows (see ref. 4):
"Group I: Venous thrombus in the renal vein not reaching IVC.
Group II: Infra-hepatic IVC thrombus.
Group III: Thrombi in retrohepatic or suprahepatic IVC not reaching the right atrium. Because of the prognostic relevance of the cranial intracaval neoplastic extension and the surgical consequences related to IVC exposure as well as the degree of vascular control required to extract these thrombi,5 group III is further subdivided according to the anatomical relation of the thrombus to the major hepatic veins6:-
     IIIa (intrahepatic): A thrombus extending into the retrohepatic IVC but below the ostia of major hepatic veins.
     IIIb (hepatic): A thrombus extending into the retrohepatic IVC reaching the ostia of the major hepatic veins and may extend into them causing Budd-Chiari syndrome.
     IIIc (suprahepatic, infradiaphragmatic): A thrombus extending into the retrohepatic IVC above the major hepatic veins but below the diaphragm.
     IIId (suprahepatic, supradiaphragmatic and infra-atrial): A thrombus extending into the supradiaphragmatic, intrapericardial IVC but not into right Atrium.
Group IV: Right atrial thrombi". (4)

A finding of IVC thrombus with no DVT history should lead to investigation of kidneys for Renal mass and renal vein tumour thrombus 

 
Case References 1.  Renal cell carcinoma extending to the renal vein and inferior vena cava: results of surgical treatment and prognostic factors. Tongaonkar HB, Dandekar NP, Dalal AV, Kulkarni JN, Kamat MR.  J Surg Oncol. 1995 Jun;59(2):94-100.

2. Inferior vena caval thrombosis.  Overview article on Radiopaedia.  http://radiopaedia.org/articles/inferior-vena-caval-thrombosis

3. Bland thrombus association with tumour thrombus in renal cell carcinoma: analysis of surgical significance and role of inferior vena caval interruption.   2012 Dec;110(11 Pt B):E449-55. doi: 10.1111/j.1464-410X.2012.11128.x. Epub 2012 Apr 30.  http://www.ncbi.nlm.nih.gov/pubmed/22540981

4.Renal Cell Carcinoma with IVC Thrombi; Current Concepts and Future Perspectives. Mohammed Ahmed Abdel-Muneem Nouh,1,2 Masashi Inui,1 and Yoshiyuki Kakehi1. Clin Med Oncol. 2008; 2: 247–256.  PMCID: PMC3161638 Published online Mar 26, 2008.
 
Technical Details
GE Logiq E9 with C1-5 Transducer with Colour & PD ability.
Different scanning planes to access scanning windows.
Original Renal lesion found on Non-con CT & referred to prior to U/S
 
Follow Up In view of age, medical history and diagnostic findings patient was referred to palliative care.
 
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